Note: Your Results will be displayed after Submission.

The Patient Health Questionnaire (PHQ-9)

Name*
First Last
Email*
Date of Visit*
Date Format: MM slash DD slash YYYY
Phone*
The Patient Health Questionnaire (PHQ-9)
Over the last 2 weeks, how often have you been bothered by the following problems?
Little interest or pleasure in doing things*
Not at all Several Days Half the Days Nearly Every Day
Feeling down, depressed or hopeless*
Not at all Several Days Half the Days Nearly Every Day
Trouble falling asleep, staying asleep, or sleeping too much*
Not at all Several Days Half the Days Nearly Every Day
Feeling tired or having little energy*
Not at all Several Days Half the Days Nearly Every Day
Poor appetite or overeating*
Not at all Several Days Half the Days Nearly Every Day
Feeling bad about yourself - or that you're a failure or have let yourself or your family down*
Not at all Several Days Half the Days Nearly Every Day
Trouble concentrating on things, such as reading the newspaper or watching television*
Not at all Several Days Half the Days Nearly Every Day
Moving or speaking so slowly that other people could have noticed. Or, the opposite - being so fidgety or restless that you have been moving around a lot more than usual*
Not at all Several Days Half the Days Nearly Every Day
Moving or speaking so slowly that other people could have noticed. Or, the opposite - being so fidgety or restless that you have been moving around a lot more than usual*
Not at all Several Days Half the Days Nearly Every Day
Thoughts that you would be better off dead or of hurting yourself in some way*
Not at all Several Days Half the Days Nearly Every Day
If you checked off any problems, how difficult have those problems made it for you to Do your work, take care of things at home, or get along with other people?*
Not difficult at all Somewhat difficult Very difficult Extremely difficult

Note: Your Results will be displayed after Submission.

The Patient Health Questionnaire (PHQ-9)

The Patient Health Questionnaire (PHQ-9)

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